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Quality Measurement in Cardiac Surgery

David M. Shahian, MD, Jeffrey P. Jacobs, MD, Marshall L. Jacobs, MD, Sean M. O’Brien, PhD

Key Points

  • Cardiac surgery has been the leader in healthcare quality measurement for decades. Cardiothoracic surgeons have been systematically measuring quality and using those data to improve performance since the late 1980s, initially motivated by the federal government’s publication of inadequately adjusted CABG mortality reports.
  • Risk adjustment is essential for fair and accurate estimation of the quality of care. Comparing raw mortality rates among hospitals, without adequate information about case severity, is inappropriate and misleading. Outcomes must be interpreted in the context of patients’ preoperative risk factors, ideally using detailed clinical registry data rather than claims data.
  • The STS National Database was created to support accurate quality benchmarking and improvement. STS recognized the need for a standardized clinical data source, collected prospectively by trained data managers. This led to implementation of the STS National Database in 1989.
  • Mortality alone is an essential but incomplete measure of quality. Mortality alone, even if risk adjusted, is not an adequate end point, because major complications such as stroke or dialysis-dependent renal failure can profoundly impact the quality of life of survivors. This recognition was a major motivation for more comprehensive quality metrics, such as STS composite measures.
  • STS composite measures provide a more comprehensive estimate of performance. The STS portfolio of composite quality measures, first implemented in 2007, combines multiple domains such as risk-adjusted mortality, major complications, and for CABG, evidence-based process measures. This provides a more comprehensive perspective on quality and improves the ability to identify performance differences among programs.

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Last updated: September 18, 2026